Sex Disabil https://doi.org/10.1007/s11195-017-9514-8 COMMENTARY

Psychodrama and the Emotional State of Women Dealing with Infertility ¨ zkan1 Candan Terziog˘lu1 • Birgu¨l O

Ó Springer Science+Business Media, LLC 2017

Abstract This study aims to investigate the effects of psychodrama on feelings of depression, anxiety, and hopelessness, as well as the level of self-esteem in female patients with infertility. The study sample consisted of 30 female patients with infertility, who applied to the In Vitro Fertilisation Unit of a university hospital in Ankara. Initially, Beck’s Depression Inventory, Beck’s Anxiety Inventory, Beck’s Hopelessness Scale, and the Rosenberg Self-Esteem Scale were administered to recruited patients twice, before and after the start of the psychodrama practice. 8 weeks of psychodrama were practised with the sample group for 3 h per week. In each group session, the aim was for women to acknowledge their emotions and share their challenges during the infertility treatment process through psychodrama games. The IBM SPSS Statistics 21.0 program (Istanbul, Turkey), Shapiro–Wilk test, Mann–Whitney U test, and Wilcoxon test were used for statistical analysis and calculation. The results showed significant differences between participants’ pre and post-test scores on Beck’s Depression, Beck’s Anxiety, Beck’s Hopelessness, and the Rosenberg Self-Esteem Scale. However, there was no significant difference between participants’ pre and post-test scores on Beck’s Anxiety Inventory; post-test scores were lower than pre-test scores. It was shown that group therapy for female patients with infertility. This result shows that psychodrama may enhance self-esteem, despair, anxiety and depression. Keywords Infertility
Psychodrama
Group intervention
Psychosocial supply
Turkey

& Candan Terziog˘lu [email protected] ¨ zkan Birgu¨l O [email protected] 1

Department of Nursing, Faculty of Health Sciences, Ankara Yıldırım Beyazıt University, Ankara, Turkey

123

Sex Disabil

Introduction Although not a life-threatening illness, infertility is recognized to be a psychosocial state affecting individuals, families, and society, with devastating effects on individuals [1, 2]. Infertility affects both women and men by creating physical, psychological, and physiological problems [3–5]. Studies have shown that the mental health problems experienced by infertile couples include depression, distress, loss of control, anxiety, isolation, and hopelessness [6, 7]. Stewart and Robinson (1989) showed that 15% of men and 50% of women describe infertility as the most upsetting experience of their lives [8]. Collins and Freeman (1992) have asserted that women show higher levels of stress response to infertility than men [9]. Golombok [10] showed that women exhibit higher levels of guilt, anger, isolation, and feelings of being punished than do men. Other studies have reported that when women cannot get pregnant after infertility treatment, they exhibit lower levels of hope [11–14]. Infertility affects relationships, and it causes marital and sexual dissatisfaction [15]. Most infertile couples note conflicts, dissociation, disagreements over medical treatments, apathy, and different attitudes towards investments in infertility therapies [15–18]. Mental health problems in infertile couples negatively affect the prevalence of pregnancy and marital and sexual dissatisfaction. Today, infertility treatments must include psychosocial interventions [19]. One form of psychosocial intervention is psychotherapy, which reduces and eliminates feelings of tension, anxiety, fear, discomfort, and breakdown arising from these conflicts. Psychotherapy can promote mental harmony, and it helps individuals develop peaceful relationships with themselves and others [16, 17]. Many studies have investigated the effects of various psychosocial interventions, which can take the form of individual, couple, and group therapies involving cognitive, behavioural, and group-based therapies. All of these intervention methods aim to uncover the emotional effects of infertility [15]. Psychosocial interventions are used to prevent and reduce various mental health problems, such as anxiety, depression, phobias, and marital and sexual dissatisfaction. At the same time, psychosocial interventions are suggested to be more effective before the start of infertility treatment [22, 23]. Psychosocial interventions increase the chance of pregnancy and develop the couple’s outlook by guiding them [22, 23]. Emery et al. [24] emphasised that couples who undergo psychological counselling (on technical issues, for psychological support, and relationship-focused counselling) during their first attempt at in vitro fertilisation are satisfied with having done so. Many experimental studies have been designed to investigate infertile couples’ marital relations and emotional distress and the effects of infertility on these outcomes [25–27]. There are various psychosocial approaches used for infertility in women. These approaches can be either individual- or group-based [28]. One such psychosocial intervention is the practice of psychodrama. Developed by the Australian psychiatrist Jacop Moreno, psychodrama is a method of group therapy that aims to re-explore reality through dramatisation. Psychodrama involves ‘‘Action Methods’’ and is a type of group psychotherapy that specifically emulates real life. Here, action is a distinctive feature of psychodrama that approximates real life. Re-dealing with the problem and its real aspects, questioning, and staging are the basics of psychodrama [20, 21]. A psychodrama technique with a specific application is used in this study. Being informed about the psychosocial problems that may arise during the treatment process facilitates women’s adaptations to infertility and the treatment process itself, which increases the chance of successful treatment. If women are aware of the psychological problems that may occur during

123

Sex Disabil

infertility treatments, they can become empowered to facilitate their compliance with treatment processes and also decrease the incidence of sexual problems and increase their chances of success. A small number of similar studies have been conducted in Turkey and worldwide about the effects of psychodrama on infertile individuals [20, 21]. This study aims to investigate the effects of psychodrama on feelings of depression, anxiety, and hopelessness and level of self-esteem in female patients with infertility.

Materials and Method Research Design Mixed methods were used in this investigation. Qualitative and quantitative data were collected simultaneously according to the experimental design. The quantitative part of the research consisted of pre-test and post-test measures and used a sampling method with experimental and control groups. The qualitative part of the study employed observation, interview techniques, and case-study methods.

Scales and Forms In order to collect data, a socio-demographic information form designed by the researchers was used. In addition, Beck’s Depression Inventory, Beck’s Anxiety Inventory, Beck’s Hopelessness Scale, and the Rosenberg Self-Esteem Scale were used [29–34].

Research Sample The study sample consisted of 30 female patients with infertility who visited the in vitro fertilisation unit of a university hospital in Ankara between 1 April 2015 and 30 April 2015. These individuals satisfied the inclusion criteria and agreed to take part in the study. The patients were informed about the group practice, and those who agreed to take part were informed about the nature of the psychodrama practice.

Inclusion Criteria 1. 2. 3. 4. 5.

Female gender A diagnosis of infertility No diagnosis of a mental illness Written consent to take part in the investigation Having not participated in other research within the last 6 months

After the recruitment process, the patients were divided into two groups of 15 people. This group size was determined in view of the fact that psychodrama groups are closed groups and the number of participants might decrease during the course of the study through attrition. Patients were listed according to the recruitment criteria. The first 15 patients on the list were allocated to the first group and the rest were allocated to the second group. Although 15 participants were allocated to the first group, only 9 participants took part in the first session. In total, 7 individuals and 6 individuals joined the second and third sessions, respectively. The following sessions were held and completed with 6 people. Similarly, although 15 people were allocated to the second group, 13 people took part in

123

Sex Disabil

the first session. Further, 9 individuals and 5 individuals joined the second and third sessions, respectively. The following sessions were held and completed with 5 participants. The patients who left the groups reported that they did not want to continue, and they were accordingly excluded from the groups. New patients were not recruited because the study group was a closed group.

Ethical Dimensions of the Research Yıldırım Beyazıt University Ethics Commission approved our study entitled ‘‘Psychodrama And The Mental State of Female Patients with Infertility’’ before we started working with the patients.

Psychodrama Practice in the Research In the first part of the study, Beck’s Depression Inventory, Beck’s Anxiety Inventory, Beck’s Hopelessness Scale, and the Rosenberg Self-Esteem Scale were administered to the recruited patients twice in total, before and after the start of psychodrama practice. 8 weeks of psychodrama were practised with the sample group. Psychodrama practices were held each week on the same day at the same time for 3 h. In each group session, the aim was for women to acknowledge and explain their emotions and share their emotional challenges during the infertility treatment process through playing psychodrama games. A researcher certified in psychodrama practices led the sessions. Psychodrama sessions are generally composed of three phases: warm-up, action, and sharing.

Statistical Analysis Qualitative and quantitative analyzes were used to evaluate the intervention. In the quantitative part of the study, the Shapiro–Wilk test was used to analyze the distribution of continuous variables such as age and score on Beck’s Depression Inventory, Beck’s Anxiety Inventory, and Beck’s Hopelessness Scale. Normally distributed variables were reported as mean ± standard deviation (SD), and non-normally distributed variables were reported as medians (min–max: minimum–maximum). Categorical variables such as education and income levels were reported as numbers with percentages: n (%). The Mann–Whitney U test was used to compare the scale scores of Groups 1 and 2; the Wilcoxon test was used to compare pre-test and post-test scale scores within the groups. Test statistics and p values were reported, and the statistical significance level was set at p \ 0.05. IBM SPSS Statistics 21.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analysis and calculations. In the qualitative part of the study, the concepts individually used by participants were analyzed. These concepts were categorised from general to specific, and sub-concepts were identified through a reductive approach.

123

Sex Disabil

Results Quantitative Data on the Psychodrama Process Based on the results of this study, the scores on Beck’s Depression Inventory, Beck’s Anxiety Inventory, Beck’s Hopelessness Scale, and the Rosenberg Self-Esteem Scale for female patients with infertility were summarised. The pre-median score on Beck’s Anxiety Inventory was found to be 11.50 (min–max: 1.0–43.0), and the post-median score was found to be 4.0 (min–max: 0.0–24.0). The pre-average score on Beck’s Depression Inventory was 18.55 ± 8.20, and the post-average score was 7.36 ± 5.70. Furthermore, the pre-median score on Beck’s Hopelessness Scale was 11.50 (min–max: 1.0–16.0), and the post-median score was 2.0 (min–max: 1.0–6.0). The pre-average score on the Rosenberg Self-Esteem Scale was 17.05 ± 3.71, and the post-average score was found to be 21.09 ± 3.36 (Tables 1, 2). The results revealed significant differences between participants’ pre-test and post-test scores on Beck’s Depression Inventory, Beck’s Anxiety Inventory, Beck’s Hopelessness Scale, and the Rosenberg Self-Esteem Scale (p \ 0.05). However, there was no significant difference between participants’ pre-test and post-test scores on Beck’s Anxiety Inventory. Even so, the post-test scores were lower than the pre-test scores (p [ 0.05). No significant difference was found in the intra-group and inter-group comparisons of scores on Beck’s Depression Inventory, Beck’s Anxiety Inventory, Beck’s Hopelessness Scale, and the Rosenberg Self-Esteem Scale (p [ 0.05).

Qualitative Data on the Psychodrama Process The 8 weeks of psychodrama sessions aimed to raise participants’ awareness of their emotions, thoughts, and bodily sensations; increase participants’ transmission of emotions; allow participants to practise stress management and relief techniques; help participants develop effective and satisfactory communication patterns with others and improve their communication skills; change the participants’ perspectives; allow the participants to develop problem-solving skills and transfer emotions; reduce the emotional pressure experienced by the participant; raise participants’ awareness of their existing power resources; and develop the participants develop new power resources. In general, the psychodrama sessions aimed to create awareness in the participants of their needs during the treatment process and help them explore their needs. In the first session of the psychodrama practice, pre-tests were administered and the participants were informed about the nature of the group therapy, its principles, and the rules of psychodrama. Subsequently, groups moved to the game phase, and warm-up games were chosen and played to familiarise the participants with one other. In the second session, the director asked the participants about the emotions they had when they joined the psychodrama session. A warm-up game was carried out to enable the participants to uncover their emotions. Emotions that were uncovered at the end of the game included ‘‘anxiety, fear, pessimism, fear of death, and happiness.’’ In the third session, the director invited the participants to play two different games. In the sharing phase, participants reported that they felt understood, and they recognized the fact that the inability to express their emotions had become a burden on themselves and started to relieve themselves of that burden during the sessions. The most intense emotion during the session was ‘‘feeling understood.’’ In the fourth session, participants reported their worries about the decrease in

123

Sex Disabil Table 1 The distribution of demographic characteristics of female patients with infertility

Demographic data

Average ± standard deviation (SD) n (%)

Age

32.32 ± 4.84

Educational status Primary school

5 (22.7)

Middle school

6 (27.3)

High school

6 (27.3)

University

5 (22.7)

Working status Working

6 (27.3)

Not working

16 (72.7)

Income status Low

3 (13.6)

Intermediate

15 (68.2)

High

4 (18.2)

Social insurance status Owned

22 (100.0)

Not owned

0 (0.0)

Demographic data

Median (min–max) n (%)

Duration of marriage

7.0 (1.0–19.0)

The length of cannot conceive unless contraception

5.0 (1.0–19.0)

Previous history of pregnancy Yes

4 (18.2)

No

18 (81.8)

Number of times assisted reproduction technique attempted Once

8 (36.4)

Twice

8 (36.4)

Three times or more

6 (27.2)

Infertile partner Woman

12 (54.5)

Man

1 (4.5)

Both partners

4 (18.3)

Unclear

5 (22.7)

the number of participants. The director chose a related warm-up game for the participants to release their worries. In the sharing phase, participants expressed their worries about a further decrease in the number of participants and the threat of disintegration of the group. The most intensely expressed emotions were anxiety and fear. Afterwards, participants played a game to reveal experiences in their lives that created similar anxieties. After the game, some of the participants shared their emotions about the in vitro fertilisation process and its possible negative results. The most intensely experienced feeling in the group was that ‘‘they were not alone; there were other people who were going through the same

123

Sex Disabil Table 2 Participants’ views of their achievements in psychodrama group practice Groups 1 and 2 sessions

Aims

Participants’ views of their achievements

Session 1

Providing information about the group therapy process and psychodrama

I realised that I only ask questions about in vitro fertilisation. (P1-P2-P3-P4-P5-P7P8-P9-P11-P13-P15-P16-P18-P20-P22)

Familiar rising group members with each other

I found the games we play motivating. (P1P2-P4-P5-P8-P9-P11-P13-P15-P18-P20P22)

Helping female patients with infertility to perceive the group as a safe environment Developing role-playing skills in group members Session 2

Creating a trust worthy environment among the group members

I feel relieved thanks to releasing my emotions. (P1-P2-P4-P5-P7-P11-P13-P15P16-P17-P18-P20)

Enabling group members to express their emotions

I could express myself more easily thanks to our practice. (P1-P2-P4-P6-P7-P11-P13P15-P16-P17-P18-P19)

Developing empathy skills in group members

I believed that I feel better to learn about my friends’ emotions and I do not feel alone anymore. (P1-P3-P4-P5-P7-P10-P13-P15P16-P17)

Enabling group members to acknowledge and express their emotions and thoughts Session 3

Session 4

Creating awareness in group members

I found a job after starting the group. (P2P12)

Enabling group members to transfer their emotions

I started knitting again. (P1-P14)

Allowing group members to release their emotions

Not being able to express my emotions felt like a burden to me. I realised this here. I started letting go of my burdens, and I feel understood. (P1-P2-P3-P4-P6-P10-P11P13-P14)

Providing an opportunity for group members to talk about important incidents in their lives

I blamed myself a lot during that process. There were many emotional burdens. It made me feel better to live through this again. This session made me feel a lot better to talk about emotions. I found a chance to let go of my burdens. (P1-P11-P13)

Supporting group members in uncovering their emotions and becoming protagonists

I had been through similar situations before and it was very difficult to deal with it. Putting myself into his place enabled me to release my emotions. (P2-P3-P10-P12-P14)

Inviting group members to express their experiences with in vitro fertilisation and allowing them to release their emotions Session 5

Evaluating the group process

The protagonist game we played last week was a turning point for me to share my emotions. (P1-P2-P3-P4-P6-P10-P11-P13P14)

123

Sex Disabil Table 2 continued Groups 1 and 2 sessions

Session 6

Aims

Participants’ views of their achievements

Helping group members to acknowledge their competencies

I learned to develop empathy. Feeling common emotions made me feel not alone and I felt understood. (P1-P2-P3-P10-P12P14)

Enabling group members to express their emotions

I can release my thoughts and I can express my emotions and thoughts easily. (P1-P3P4-P5-P6-P10-P12-P13-P14).

Enabling group members to express their emotions

I realised that I cannot be patient. I learned that I should sometimes keep things for another time. (P3-P5-P6-P13)

Supporting group members in the role of protagonist

I made decisions for myself; I am going to start exercising. (P4-P12)

Providing group members with positive feedback

I gained self-confidence. (P1-P2-P3-P4-P5P10-P11-P12-P13-P14) I was angry at myself sometimes. I realised that I should share my responsibilities. (P5P6- P13-P14)

Session 7

Helping group members to acknowledge their strengths and weaknesses

What I had been through emotionally was not important before. Now, I care about it. I feel much better now. (P1-P2-P3-P5-P6-P10P11-P13-P14)

Inviting group members to evaluate themselves as a group and individually

I was only focused on in vitro fertilisation. I realised that it often makes me tired. (P1P2-P3-P4-P5-P10-P11-P12-P13-P14) I realised that I often made myself tired with the idea of having a baby. I could not even enjoy my marriage. I am not obsessed with the idea of having a baby anymore. (P2-P3P4-P5-P10-P12-P14) I discover myself more and more each week. (P1-P2-P4-P5-P6-P10-P11-P12-P14)

Session 8

Enabling group members to acknowledge what they feel during and outside the sessions

I felt trapped and overwhelmed all the time. These feelings have become less intense over time. (P2-P4-P5-P6-P10-P12-P13)

Helping group members find a balance between their rational thoughts and emotions

I realised that I was living only in my own world before. I was hopeless and I paid so much attention to what other people think. I started caring about myself after the group. I have not been wearing makeup; I started wearing it again. (P2-P4-P5-P11-P13)

Inviting group members to evaluate the process and themselves

I can stand on my own feet now. (P2- P12P14) I feel lucky. My priorities have changed. I have decided to enjoy my marriage. I feel peaceful and happy inside. (P1-P3-P6-P12P13-P14)

123

Sex Disabil Table 2 continued Groups 1 and 2 sessions

Aims

Participants’ views of their achievements

I think health is the most important thing. I am not obsessed with the treatment anymore. I will let my body rest for a while, then I will start the treatment again. (P1-P2P4-P5-P6-P10-P11-P12-P14) Communication with my husband has improved. I felt a lot better when I realised that my husband has also been changing like myself. (P1-P2-P4-P6-P10-P12-P13-P14) P Participant/P1–P9: Group 1 members/P10–P22: Group 2 members

anxieties as them.’’ In the fifth session, participants reported that the previous session was a turning point for them to share their emotions. Thus, each of the participants experienced the feeling of being a protagonist. The most intense feeling in the group was ‘‘relief of sharing their emotions.’’ In the sixth session, the director invited the participants to play a game in which each participant played the protagonist role in their own scenario. Additionally, each participant reported the changes they noticed in themselves. The most intensely experienced feeling in the group was ‘‘relief, well-being, and feelings of motivation brought about by change.’’ In the seventh session, after the sharing of emotions, participants played a warm-up game. During the sharing phase, participants talked about changing situations in their lives and the reactions of the people around them to those changes. The most intensely experienced feeling in the group was that ‘‘it was previously difficult to deal with the challenges of infertility, but now they could talk and start dealing with those challenges.’’ In the eighth session, the last session, after the sharing of emotions, an evaluation game was played to help the participants to see the importance of the process in their lives. After the sharing phase, the therapy ended. The participants expressed that the group ‘‘raised their awareness and developed their competence skills; a baby was not the only focus in their lives and they realised that they themselves were also valuable.’’

Conclusion The aim of this research was to investigate the effect of psychodrama on depression, anxiety, hopelessness, and the level of self-esteem experienced by female patients with infertility. The results revealed significant differences between participants’ pre-test and post-test scores on Beck’s Depression Inventory, Beck’s Anxiety Inventory, Beck’s Hopelessness Scale, and the Rosenberg Self-Esteem Scale. However, there was no significant difference between participants’ pre-test and post-test scores on the Beck’s Anxiety Inventory. Even so, the post-test scores were lower than pre-test scores in this inventory. A study conducted by Hammerli et al. [35] showed that anxiety and depression

123

Sex Disabil

symptoms in female patients with infertility dropped after psychotherapy, and the level of decrease in depression symptoms was greater than the level of decrease in anxiety symptoms [35]. Mosalanejad et al. [36] investigated the effects of cognitive-behavioural group therapy on stress, anxiety, and depression symptoms in female patients with infertility. These authors showed that there was a meaningful difference between pre-group and post-group symptoms and scores, with post-group symptoms and scores being lower than the pre-group ones. At the same time, the results of this study revealed a beneficial effect on infertility by improving mental health in terms of coping with stressful life events and reducing psychological stress [36]. A study conducted by Domar et al. [37] tested the effects of group therapy on decreasing the level of anxiety and depression in female patients with infertility [37]. De Liz et al. [38] reported that psychotherapy decreased the levels of depression and anxiety in infertile women while increasing the chance of pregnancy at the same time [38]. The present study demonstrated that anxiety and depression scores of the female patients with infertility participating in the study were lower after psychodrama group practice, and there was a significant difference between the pre-test and post-test depression scores. Our analysis confirms similar results as previous studies conducted in this field. In a study conducted by Kupka et al. (2003), female patients with infertility reported during and after a course of therapy the positive effects of being advised on identifying and dealing with stress [39]. Quantitative data and observations made during the group sessions in our investigation also confirmed that female patients with infertility benefited from psychodrama sessions and that these sessions contributed to their personal development. A study conducted by Mosalanejad et al. (2013) aimed to determine the effects of psychotherapy on perceived psychological stress and anxiety caused by infertility in female patients with infertility. They practised logotherapy—a type of psychotherapy—with the experimental group for 2 hours per week for 12 sessions in total. The study demonstrated that logotherapy was an important way of reducing stress levels, and the sessions decreased levels of perceived stress, anxiety, and psychiatric symptoms. At the same time, logotherapy was effective in terms of developing infertile women’s skills and helping them to find meaning in their lives [40]. Some studies have confirmed the results of the studies noted above in terms of the positive effects of psychodrama on depression, anxiety, and hopelessness scores in female patients with infertility. Hughes and da Silva [41] practised art therapy with 21 female patients with infertility for 2 h per week for 8 weeks in total. Beck’s Depression Inventory, Beck’s Anxiety Inventory, and Beck’s Hopelessness Scale were administered before and after the art-therapy sessions. After 8 weeks of practice, there was a significant difference between scores on Beck’s Depression Inventory and Beck’s Hopelessness Scale; however, there was no significant difference between scores on Beck’s Anxiety Inventory [41]. Vizheh et al. [42] conducted a study to determine the effects of counselling on infertile couples’ marital relationships and sexual satisfaction. This study was performed as a randomised controlled trial in which 100 infertile couples who visited the Reproductive Health Research Centre in Tehran, Iran were randomly assigned to two groups: intervention and control. The outcomes, including changes in marital satisfaction and sexual satisfaction, were compared between the two groups 3 months later. Infertility counselling improved marital and sexual satisfaction in infertile couples [42]. Another study by Vizheh et al. [3] was conducted to determine the effect of a genderspecific infertility diagnosis on infertile couples. The outcomes included differences in marital satisfaction and sexual satisfaction between wives and husbands based on the infertility diagnosis. In infertile couples, wives expressed less marital and sexual

123

Sex Disabil

satisfaction than their husbands. Wives with female-factor infertility had less marital satisfaction, and those whose husbands had male-factor infertility had less sexual satisfaction than their wives with infertility resulting from other factors. Husbands whose wives had female-factor infertility had less marital satisfaction than husbands with infertility resulting from other factors. Husbands whose wives had female-factor infertility had less marital satisfaction and those who had male-factor infertility exhibited significantly less sexual satisfaction than those with infertility resulting from other factors. One can conclude that an infertility diagnosis has a significant impact on infertile couples in terms of marital and sexual satisfaction [3]. An analysis of the studies conducted in this area demonstrates that Beck’s Depression Inventory, Beck’s Anxiety Inventory, and Beck’s Hopelessness Scale are sometimes used individually and sometimes used together in psychotherapy and counselling practices. Distinctively, in our study we also used a self-esteem measure. Furthermore, we collected and analyzed qualitative data in addition to quantitative data. Our results indicated that psychodrama-based group therapy for female patients with infertility might have beneficial effects in terms of reducing and dealing with the psychological symptoms caused by infertility. Other research suggests that the reduction in psychological distress experienced by infertile women will be reflected in their marital relations, sexual satisfaction, and interpersonal relationships [41, 42]. Looking at practices in Turkey, we see that complementary studies are held up as successful and preventive and interventionist studies are underestimated. For this reason, this study can contribute to investigating interventions for infertile women, as well as to the practices of experts and practitioners in psychological/health counselling. Repeating this study with a larger group of patients and making comparison with experimental-control groups while evaluating the effectiveness of the study by conducting follow-up studies will be important for future studies.

Limitations of the Research Regarding the limitations of this study, the number of participants decreased after study began. The effect of duration of the group practice on participants could not be evaluated because we could not conduct a follow-up study to analyze the sustainability of the effect of group practice on participants. For this reason, a follow-up study should be conducted in the future. Additionally, our conclusions are limited to the participants of this study. Funding This work was partially funded by the researchers. Compliance with Ethical Standards Conflict of interest Both authors declares that they have no conflict of interest. Ethical Approval All of the procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent Online informed consent was stated and therefore obtained from all individual participants included in the study. No sensitive or identifiable data were collected for the purpose of this study.

123

Sex Disabil

References 1. Lee, S.H.: Effects of using a nursing crisis intervention program on psychosocial responses and coping strategies of infertile women during invitro fertilization. J. Nurs. Res. 11(3), 197–208 (2003) ¨ zc¸elik, B., Karamustafalıog˘lu, O., O ¨ zc¸elik, A.: Psychological and psychiatric aspects of infertility. 2. O Anatol. J. Psychiatry 8, 140–148 (2007) 3. Vizheh, M., Pakgohar, M., Rouhi, M., Veisy, A.: Impact of gender infertility diagnosis on marital relationship in infertile couples: a couple based study. Sex. Disabil. 33, 457–468 (2015). https://doi.org/ 10.1007/s11195-015-9417-5 4. Andrews, F.M., Abbey, A., Halman, L.J.: Stress from infertility, marriage factors and subjective wellbeing of wives and husbands. J. Health Soc. Behav. 32, 238–253 (1991) 5. Gourounti, K., Anagnostopoulos, F., Potamianos, G., et al.: Perception of control, coping and psychological stress of infertile women undergoing women undergoing IVF. Reprod. Biomed. Online. 24(6), 670–679 (2012) 6. Valentin, D.P.: Psychological impact of infertility: identifying issues and needs. Social Work Health Care 11(4), 61–69 (1986) 7. Moller, A., Fallstrom, K.: Psychological factors in the etiology of infertility: a longitudinal study. J. Psychosom. Obstet. Gynecol. 12(1), 13–21 (1991) 8. Stewart, D.E., Robinson, G.E.: Infertility by choice or by nature. Can. J. Psychiatry/La Revue canadienne de psychiatrie. 34, 866–871 (1989) 9. Collins, A., Freeman, E.W., Boxer, A.S., et al.: Perceptions of infertility and treatment stress in females as compared with males entering invitro fertilization treatment. Fertil. Steril. 57, 350–356 (1992) 10. Golombok, S.: Psychological functioning in infertility patients. Hum. Reprod. 7, 208–212 (1992) 11. Boivin, J., Takefman, J.E.: Stress level across stages of invitro fertilization in subsequently pregnant and nonpregnant woman. Fertil. Steril. 64(4), 802–810 (1995) 12. Beutel, M., Kupfer, J., Kirchmeyer, P., et al.: Treatment-related stresses and depression in couples undergoing assisted reproductive treatment by IVF or ICSI. Andrologia. 31(1), 27–35 (1999) 13. Mogobe, D.K.: Denying and preserving self: batswana women’s experiences of infertility. Afr. J. Reprod. Health. 9, 26–37 (2005) 14. Cedars, M.I.: Infertility: Practical Pathways in Obstetrics and Gynecology. McGraw-Hill, New York (2005) 15. Orji, E.O., Ogunniyi, S.O.: Sexual behavior of infertile Nigerian women. J. Obstet. Gynaecol. 21(3), 303–305 (2001) 16. Audu, B.M.: Sexual dysfunction among infertile Nigerian women. J. Obstet. Gynaecol. 22(6), 655–657 (2002) 17. Braverman, A.M.: Psychosocial aspects of infertility: sexual dysfunction. Int. Congr. Ser. 1266, 270–276 (2004) 18. Lee, T., Sun, G.H., Chao, S.C.: The effect of an infertility diagnosis on treatment-related stresses. Arch. Androl. 46, 67–71 (2001) 19. Wischmann, T.H.: Psychogenic infertility—myths and facts. J. Assist. Reprod. Genet. 20, 485–494 (2003) 20. Pio-Abreu, L. J., Oliveira-Villares, C.: Psikodramaya bir kaos kuramı bakıs¸ ı. In: Baim, C., Burmeister, J., Maciel, M. (eds.) Psikodrama kuram ve uygulamadaki gelis¸ meler. London (2007) 21. Holmes, P., Karp, M., Watson, M.: Psychodrama Theory and Practice Innovation Since Moreno, Part 2 Spontaneity and Creativity. Routledge, London (2005) 22. Su, T.J., Chen, H.F., Chen, Y.C., et al.: Factors related to meaning of life in Taiwanese women treated with in vitro fertilization. J. Formos. Med. Assoc. 105(5), 404–413 (2006) 23. Domar, A.D., Broome, A., Zuttermeister, P.C., Seibel, M., Friedman, R.: The prevalence and predictability of depression in infertile woman. Fertil. Steril. 58(6), 1158–1163 (1992) 24. Emery, M., Beran, M.D., Darwiche, J., et al.: Results from a prospective, randomized, controlled study evaluating the acceptability and effects of routinepre-IVF counselling. Hum. Reprod. 18, 2647–2653 (2003) 25. Pasch, L.A., Dunkel-Schetter, C., Christensen, A.: Differences between husbands’ and wives’ approach to infertility affect marital communication and adjustment. Fertil. Steril. 77(6), 1241–1247 (2002) 26. de Klerk, C., Hunfeld, J.A.M., Duivenvoorden, H.J., den Outer, M.A., Fauser, B.C.J.M., Passchier, J., et al.: Effectiveness of a psychosocial counseling intervention for first-time IVF couples: a randomized controlled trial. Hum. Reprod. 20(5), 1333–1338 (2005) 27. Lee, T., Sun, G.H.: Psychosocial response of Chinese infertile husbands and wives. Arch. Androl. 45, 143–148 (2000)

123

Sex Disabil 28. Tuschen-Caffier, B., Florin, I., Krause, W., et al.: Cognitive-behavioral therapy for idiopathic infertile couples. Psychother. Psychosom. 68, 15–21 (1999) 29. C ¸ uhardarog˘lu, F.: Self-esteem in adolescents. Thesis, Hacettepe University Medical School Department of Psychiatry. Ankara (1986 30. Hisli, N.: A study of the validity of the Beck’s Depression Inventory. Turk. J. Psychol. 6(22), 118–122 (1988) 31. Hisli, N.: The validity and reliability of the Beck’s Depression Inventory for college students. Turk. J. Psychol. 7(23), 3–13 (1989) 32. Beck, A.T., Epstein, N., Brown, G., et al.: Differentiating anxiety from depression: a test of the cognitive content-specificity hypothesis. J. Abnorm. Psychol. 96, 179–183 (1988) 33. Seber, G., Dilbaz, N., Kaptanog˘lu, C., et al.: Hopelessness Scale: validity and reliability. J. Crisis. 1, 139–142 (1993) 34. Durak, A., Palabıyıkog˘lu, R.: Validity of the Beck’s Hopelessness Scale. J. Crisis. 2, 311–319 (1994) 35. Ha¨mmerli, K., Znoj, H., Barth, J.: The efficacy of psychological interventions for infertile patients. Hum. Reprod. Update. 15, 279–295 (2009) 36. Mosalanejad, L., Khodabakshi-Koolaee, A., Jamali, S.: Effect of cognitive behavioral therapy in mental health and hardiness of infertile women receiving assisted reproductive therapy (ART). Iran. J. Reprod. Med. 10(5), 483–488 (2012) 37. Domar, A.D., Clapp, D., Slawsby, E.A., et al.: Impact of group psychological interventions on pregnancy rates in infertile woman. Fertil. Steril. 73(4), 805–811 (2000) 38. De Liz, T.M., Strauss, B.: Differential efficacy of group and individual/couple psychotherapy with infertile patients. Hum. Reprod. 20(5), 1324–1332 (2005) 39. Kupka, M.S., Dorn, C., et al.: Stress relief after infertility treatment—spontaneous conception, adoption and psychological counselling. Eur. J. Obstet. Gynecol. Reprod. Biol. 110, 190–195 (2003) 40. Mosalanejad, L., Koolee, A.K.: Looking at infertility treatment through the lens of the meaning of life: the effect of group logotherapy on psychological distress in infertile women. Int. J. Fertil. Steril. 6(4), 224–231 (2013) 41. Hughes, E.G., da Silva, A.M.: A pilot study assessing art therapy as a mental health intervention for subfertile women. Hum. Reprod. 26(3), 611–615 (2011) 42. Vizheh, M., Pakgohar, M., Babaei, G., Ramezanzadeh, F.: Effect of counseling on quality of marital relationship of infertile couples: a randomized, co ntrolled trial (RCT) study. Arch. Gynecol. Obstet. 287, 583–589 (2013). https://doi.org/10.1007/s00404-012-2595-9

123